| NPI | 1629309398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD176080) |
| 207Q00000X Family Medicine (Licence: CA A116570) | |
| Enumeration Date | 2010-01-20 |
| Last Update Date | 2022-08-18 |